Akshat ethics in medicine


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Akshat ethics in medicine

  1. 1. AKSHAT JAIN MD New York Medical College Metropolitan Hospital Center NY, USA ETHICS IN MEDICINE
  2. 2. What may this be ?
  3. 3. <ul><li>VIGNETTE – You are breaking the news of the lethal tumor that a 8 year old has been </li></ul><ul><li>diagnosed to have , and you tell the child and the parents that the prognosis does not look very </li></ul><ul><li>good in his case. The patient breaks down and begins to cry .What should you do? </li></ul>
  4. 4. <ul><li>EFFECTIVE COMMUNICATION </li></ul>
  5. 5. <ul><li>Poor communication between physicians and their patients may be a major contributing </li></ul><ul><li>factor in deciding why patients </li></ul><ul><li>Initiate a lawsuit , OR </li></ul><ul><li>Switch their doctors. </li></ul>
  6. 6. • Basic concepts in communicating effectively. <ul><li>• Listen actively - </li></ul><ul><li>Listening for content and meaning, responding to the feelings expressed </li></ul><ul><li>by children and their families, and carefully noting all verbal and nonverbal cues. </li></ul>
  7. 7. <ul><li>• Elicit the needs and concerns of children and families. </li></ul><ul><li>Eg. Finance , stress etc </li></ul><ul><li>• Acquire skills and practice in providing individual guidance. </li></ul><ul><li>Eg. – Dialects , Body Language. </li></ul>
  8. 8. <ul><li>TRICKS ! </li></ul>
  9. 9. Motivational interviewing <ul><li>Enhances a patient’s intrinsic motivation to change by exploring their </li></ul><ul><li>perspective . </li></ul><ul><li>Rather than a set of techniques or a way of coercing treatment </li></ul><ul><li>adherence, MI explores how a person feels about the status quo and about change through EXPLORING the person’s values, interests, and concerns. </li></ul>
  10. 10. <ul><li>Express empathy </li></ul><ul><li>Ambivalence is normal </li></ul><ul><li>Roll with resistance -Resistance is not directly opposed. </li></ul><ul><li>New perspectives are invited but not imposed. </li></ul><ul><li>The client is a primary source in finding </li></ul><ul><li>answers and solutions. </li></ul><ul><li>Support self-efficacy A person’s belief in the possibility of change is </li></ul><ul><li>an important motivator. </li></ul>
  11. 11. Reflective listening <ul><li>Method both of resonating with a patient and of clarifying the meaning </li></ul><ul><li>of his or her statements. To demonstrate support of a patient’s efforts, a health care professional </li></ul><ul><li>may use affirmations. </li></ul>
  12. 13. <ul><li>Everyone knows there is no &quot;Gold Standard&quot; for ethical behavior </li></ul>
  13. 14. Defining “bad news” <ul><li>Bad news is any information that changes a person's view of the future in a negative way. Physicians frequently must </li></ul><ul><li>break bad news to patients and their loved ones. </li></ul>
  14. 15. <ul><li>Withholding bad news from patients was commonly practiced until recently. But many recent studies have finally </li></ul><ul><li>found that most patients want to know the truth about their illness. </li></ul><ul><li>• When to deliver bad news? </li></ul><ul><li>“ It’s not what you say but when and how you say it.” </li></ul><ul><li>Do not force a patient to hear bad news if the patient does not want it at that moment, but do try to discuss it with him </li></ul><ul><li>or her as soon as possible. </li></ul>
  15. 16. <ul><li>• Who should deliver bad news? </li></ul><ul><li>It’s the duty of the physician treating the patient to tell about everything. Tell the patient everything, even if he or she </li></ul><ul><li>does not ask. </li></ul>
  16. 17. <ul><li>• How to deliver bad news ? </li></ul>
  17. 18. <ul><li>The ethics of health care in today’s era emphasize patient autonomy and full disclosure . </li></ul><ul><li>Honest revelation </li></ul><ul><li>of diagnoses, prognoses, and treatment options allows patients to make informed healthcare decisions that are </li></ul><ul><li>consistent with their goals and values. </li></ul>
  18. 19. STEP WISE APPROACHES- <ul><li>3 models of ‘how to deliver bad news’ are described here: </li></ul><ul><li>--ABCDE </li></ul><ul><li>--ROBERT BUCKMAN’S 6 STEP </li></ul><ul><li>PROTOCOL </li></ul><ul><li>--THE SPIKES APPROACH </li></ul>
  19. 20. Adapted from Rabow MW, McPhee SJ. Beyond breaking bad news: how to help patients that suffer. West J Med 1999;171:261 <ul><li>A dvance preparation--Arrange adequate time and privacy, confirm medical facts, review relevant clinical data, and emotionally prepare for the encounter. </li></ul><ul><li>B uilding a therapeutic relationship-- Identify patient preferences regarding the disclosure of bad news. </li></ul><ul><li>C ommunicating well--Determine the patient's EMOTIONAL STATE </li></ul><ul><li>D ealing with patient and family reaction-- Assess and respond to emotional, reactions and empathize with the patient. </li></ul><ul><li>E ncouraging/validating emotions- Offer realistic hope based on the , patient's goals and deal with your own needs. </li></ul>
  20. 21. THE “B” - B uilding a therapeutic relationship- <ul><li>&quot;What have </li></ul><ul><li>you already been told about your illness?“ - level of technical sophistication </li></ul><ul><li>and the patient's emotional state. </li></ul><ul><li>Finding out how much the patient wants to </li></ul><ul><li>know. </li></ul>
  21. 22. “C”- C ommunicating well- <ul><li>Proceed at the patient's pace. </li></ul><ul><li>Avoid medical jargon or euphemisms, ( Eg -ANAND). </li></ul><ul><li>Allow for silence and tears, and answer questions. </li></ul><ul><li>Eg- &quot; I'm going </li></ul><ul><li>to stop for a minute to see if you have </li></ul><ul><li>questions &quot;. </li></ul>
  22. 23. Barriers to effective disclosure <ul><li>Physician fears: </li></ul><ul><li>• How will I, as the physician, cope with the patient's tears, anxiety, and fear? </li></ul><ul><li>• The fear of being blamed by the patient </li></ul><ul><li>• Fear of not knowing all of the answers sought by the patient, </li></ul><ul><li>of inflicting pain on the patient. </li></ul><ul><li>• Many physicians have had little or no formal training in how to break bad news, </li></ul><ul><li>• Many perceive a lack of time in which to present the news. </li></ul><ul><li>• Patients may have multiple physicians, making it unclear, who should break the bad news. </li></ul>
  23. 24. o The setting & posture <ul><li>• Allow enough uninterrupted time </li></ul><ul><li>• Arrange seating for comfortable, close communication. </li></ul><ul><li>• Avoid large desks and tables. </li></ul><ul><li>• If at all possible, both patient and physician should both be sitting. </li></ul><ul><li>• Ask the patient who else ought to be present, and let the patient decide--studies show that different patients </li></ul><ul><li>have widely varying views on what they would want. </li></ul>
  24. 25. EYE CONTACT <ul><li>• Make eye contact </li></ul><ul><li>• Defined touch </li></ul><ul><li>• Talk to the patient, not colleagues: patient is always the focus </li></ul>
  25. 26. EMPATHY <ul><li>Empathy is considered a mirroring or vicarious experience of another's emotions, whether they be sorrow or joy. </li></ul><ul><li>The patient relies on the physician to provide appropriate medical care and advice, as well as provide appropriate </li></ul><ul><li>psychosocial support </li></ul>
  26. 27. How I do IT <ul><li>&quot;I wish I had better news&quot; compared to &quot;I'm sorry, I have bad news“ </li></ul><ul><li>&quot;I admire your courage,&quot; &quot;I will be here for you,&quot; and &quot;What gives you hope and strength?&quot; as opposed to &quot;It could </li></ul><ul><li>be worse,&quot; </li></ul>
  27. 28. <ul><li>&quot;We all die,&quot; &quot;I understand how you feel,&quot; and &quot;Nothing more can be done.&quot; </li></ul><ul><li>”Does this news frighten you?“ </li></ul><ul><li>”What are you expecting to happen?” </li></ul><ul><li>”How specific would you like me to be?” </li></ul><ul><li>”What are your fears about what might happen?” </li></ul>
  28. 29. <ul><li>”I wish the news were different.” </li></ul><ul><li>”I’ll try to help you.” </li></ul><ul><li>”I’ll help you tell your children.” </li></ul>
  29. 30. <ul><li>VIGENNETE – </li></ul><ul><li>The crying mother of a 6 y/o male child dying from a terminal illness ,requests you to “not” tell the boy about the </li></ul><ul><li>fact that he will die soon , The parents have decided in unison not to break the news ? How would you approach to </li></ul><ul><li>this problem? </li></ul>
  30. 31. The tricky situation has to be handled very carefully. <ul><li>-“Ask the family why they don't want to tell the patient?” - This can uncover relational issues and dysfunctional </li></ul><ul><li>family dynamics. Legally, of course, you are obligated to tell the patient; however, you may negotiate. </li></ul><ul><li>- Assess the patient for inappropriate coping skills, such as suicidal or homicidal ideation . </li></ul><ul><li>People will respond differently .In some cases, people may simply have </li></ul><ul><li>to leave the office. Emotional outbursts may make you very uncomfortable. </li></ul><ul><li>Try to give the patient and family time—and privacy—to react. </li></ul><ul><li>-Patient’s degree of capacity is a deciding factor in ascertaining the degree of self-determination he or she might </li></ul><ul><li>exercise in decision-making. Thus, it is incumbent on the physician to determine capacity, up to and including </li></ul><ul><li>mature minor </li></ul>
  31. 32. TEACHING AIDS <ul><li>• Standardized patients and simulated opportunities </li></ul><ul><li>• Didactic sessions </li></ul><ul><li>• GOOGLE </li></ul><ul><li>• Exposure to real-life experiences. </li></ul>